Drug Therapy in Geriatric Patients

Question 1

Older patients are _____ to drugs and they show ___ individual variation

Answer 1

more sensitive

wider

Question 2

Older adults experience more ADRs and

Answer 2

drug-drug interaction

Question 3

Principal factors underlying ADRs and drug-drug interaction in older adults:

Answer 3

• altered pharmacokinetics secondary to organ system degeneration
• multiple and severe illness
• multi drug therapy
• poor adherence

Question 4

For incurable chronic illness, the objective is to

Answer 4

reduce symptoms and quality of life

Question 5

Decline in absorption, distribution, metabolism, and excretion of drugs ______ drug sensitivity

Answer 5

increases

Question 6

The _____ of absorption may be slowed (delayed gastric emptying and reduced splanchnic blood flow) and drug responses may be _____

Answer 6

rate

delayed

Question 7

Gastric acidity is ____ in older adults and my alter the absorption of certain drugs

Answer 7

reduced

Question 8

Some drugs require high acidity to dissolve, and their absorption may be ____

Answer 8

reduced

Question 9

Factors that alter drug distribution in older adults:

Answer 9

• increased percentage of body fat
• decreased percentage of lean body mass
• decreased total body water
• reduced concentration of serum albumin

Question 10

Increase in body fat provides storage depot for ______

Answer 10

lipid soluble drugs like propranolol which reduces plasma levels and response

Question 11

Due to decline in lean body mass and total body water, ______ become distributed in smaller volume than younger adults. The concentration is increased and causing more intense effects.

Answer 11

water soluble drugs (ethanol)

Question 12

_____ levels can be significantly reduced in older adults who are malnourished

Answer 12

albumin

Question 13

Reduced albumin levels ___ sites for protein binding of drugs causing levels of free drug to rise

Answer 13

decrease

Question 14

Rates of hepatic drug metabolism tend to ____ with age

Answer 14

decline

Question 15

Reasons for decline of hepatic drug metabolism:

Answer 15

reduced hepatic blood flow, reduced liver mass, and decreased activity of some hepatic enzymes

Question 16

Drug half-lives may be ____ thereby prolonging responses

Answer 16

increased

Question 17

Beginning in early adulthood renal function and renal drug excretion undergo______

Answer 17

progressive decline

Question 18

Most important cause of ADRs in older adults

Answer 18

drug accumulation secondary to reduced renal excretion

Question 19

Decline in renal function is a result of:

Answer 19

reductions in renal blood glow, GFR, active tubular secretion and number of nephrons

Question 20

When patients are taking drugs that eliminated by the kidneys, what should be assessed?

Answer 20

renal function

Question 21

Proper index of renal function

Answer 21

creatinine clearance

Question 22

Why test creatinine clearance and not serum creatinine levels?

Answer 22

creatinine levels do not adequately reflect kidney function in older adults because the source of serum creatinine-lean muscle mass- declines in parallel with the decline in kidney function

Question 23

creatinine levels may be ___ even though renal function is greatly____

Answer 23

normal

reduced

Question 24

Alterations in receptor properties may underlie altered sensitivity to some drugs

Answer 24

but info is limited

Question 25

Beta adrenergic blocking agents are less effective in older adults because of:

Answer 25

- a reduction in number of beta receptors | - a reduction in the affinity of beta receptors for beta rector blocking agents

Question 26

Warfarin and certain CNS depressants produced effects more intense in older adults because of:

Answer 26

increase in receptor number | receptor affinity

Question 27

ADRs are ____ times more common in older adults

Answer 27

seven

Question 28

Older adults are uncomfortable revealing____ and ____

Answer 28

alcohol and recreational drug use

Question 29

Most ADR deaths are

Answer 29

dose related

Question 30

Factors that predispose older adults to ADRs:

Answer 30

- drug accumulation secondary to reduced renal function - polypharmacy - greater severity of illness - presence of comorbidities - use of drugs that have a low therapeutic index (digoxin) - increased individual variation secondary to altered pharmacokinetics - inadequate supervision of long-term therapy - poor patient adherence

Question 31

This list identifies drugs with a high likelihood of causing adverse effects in older adults

Answer 31

Beers list

Question 32

Like the Beers list, this list has an advantage of also considering the cost of drug therapy

Answer 32

STOPP

Question 33

The set of lists that can be used to promote the selection of appropriate treatment in addition to the avoidance of inappropriate treatment

Answer 33

START/STOPP

Question 34

Nonadherence can result in

Answer 34

therapeutic failure from under dosing or erratic dose or toxicity from overdosing

Question 35

Most common nonadherence

Answer 35

under dosing with therapeutic failure

Question 36

Examples of unintentional nonadherence:

Answer 36

forgetfulness failure to comprehend instructions inability to pay use of complex regimens

Question 37

Reasons for intentional nonadherence

Answer 37

patients conviction that the drug was not needed in the dosage prescribed, unpleasant side effects, price

Question 38

Promoting adherence for unintentional nonadherence:

Answer 38

- simplify regimen with smallest number of drugs and doses per day - explain treatment plan with clear, concise, verbal and written instructions - choose appropriate dosage form (liquid for difficulty swallowing) - larger print on drug containers and easy to open containers for patients with arthritis - suggest use of calendar, diary, pill counter - ask if patient has access to pharmacy and can afford meds - enlist help - monitor for therapeutic responses, ADRs, and plasma drug levels

Question 39

Promoting adherence for intentional nonadherence:

Answer 39

intensive education

Question 40

End of life goals

Answer 40

shift from disease prevention and management to provision of comfort measures

Question 41

Meds that were once considered important in care like for cholesterol management may:

Answer 41

no longer be relevant and can be discontinued

Question 42

End of life drug of choice for constipation

Answer 42

first line choices are osmotic laxatives (lactulose, polyethylene glycol) stool softener are second line if abdominal cramping is a concern bisacodyl suppositories or enemas for patients that cannot swallow

Question 43

End of life drug of choice for delirium

Answer 43

haloperidol or olanzapine | Benzos like midazolam for acute episodes

Question 44

End of life drug of choice for dyspnea

Answer 44

oxygen if hypoxemia present opioids, first line drug of choice glucocorticoids bronchodilators if associated with bronchospasm

Question 45

End of life drug of choice for fatigue

Answer 45

dexamphetamine | methylphenidate

Question 46

End of life drug of choice for N/V

Answer 46

ondansetron, aprepitant, dexamethasone metoclopramide for gastroparesis and liver failure haloperidol for unknown causes, bowel obstruction or renal failure glucocorticoids secondary to brain tumors and bowl obstructions

Question 47

End of life drug of choice for pain

Answer 47

fentanyl for patient with renal/hepatic dysfunction | methadone for patients with renal dysfunction without hepatic dysfunction

Question 48

End of life drug of choice for respiratory secretions

Answer 48

anticholinergics- glycopyrrolate